Pauline Y Ng1,2, Andrew K-Y Ng3,4, Balachundhar Subramaniam5, Sara M Burns1, Fanny Herisson6, Fanny P Timm, Cand Med1, Maira I Rudolph, Cand Med1, Flora Scheffenbichler, Cand Med1, Sabine Friedrich, Cand Med1, Timothy T Houle1, Deepak L Bhatt3, Matthias Eikermann1,5. 1. Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. 2. Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong SAR, China. 3. Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts. 4. Cardiac Medical Unit, Grantham Hospital, Hong Kong SAR, China. 5. Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. 6. Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
Abstract
Importance: Perioperative stroke is a major complication for patients undergoing surgery. Patent foramen ovale (PFO) represents a possible anatomical link between venous thrombosis and stroke. Objective: To determine whether a preoperatively diagnosed PFO is associated with increased risk of perioperative ischemic stroke. Design, Setting, and Participants: Retrospective cohort study from Massachusetts General Hospital and 2 affiliated community hospitals between January 1, 2007, and December 31, 2015. Participants were 182 393 consecutive adults undergoing noncardiac surgery with general anesthesia. Exposures: Preoperatively diagnosed PFO. Main Outcomes and Measures: Perioperative ischemic stroke occurring within 30 days of surgery; stroke subtype by Oxfordshire Community Stroke Project classification and stroke severity by National Institute of Health Stroke Scale (NIHSS). Results: Among the 150 198 patient cases analyzed (median [SD] age, 55 [16] years), 1540 (1.0%) had a diagnosis of PFO before surgery. A total of 850 (0.6%) ischemic strokes occurred within 30 days of surgery (49 [3.2%] among patients with PFO and 801 [0.5%] among patients without PFO). In adjusted analyses, patients with PFO had an increased risk of ischemic stroke compared with patients without PFO (odds ratio, 2.66 [95% CI, 1.96-3.63]; P < .001). The estimated risks of stroke were 5.9 for every 1000 patients with PFO and 2.2 for every 1000 patients without PFO (adjusted absolute risk difference, 0.4% [95% CI, 0.2%-0.6%). Patients with PFO also had an increased risk of large vessel territory stroke (relative risk ratio, 3.14 [95% CI, 2.21-4.48]; P < .001) and a more severe stroke-related neurologic deficit measured by NIHSS (median, 4 [interquartile range {IQR}, 2-10] vs median, 3 [IQR, 1-6] for those without PFO; P = .02). Conclusions and Relevance: Among adult patients undergoing noncardiac surgery at 3 hospitals, having a preoperatively diagnosed PFO was significantly associated with increased risk of perioperative ischemic stroke within 30 days after surgery. Further research is needed to confirm these findings and to determine whether interventions would decrease this risk.
Importance: Perioperative stroke is a major complication for patients undergoing surgery. Patent foramen ovale (PFO) represents a possible anatomical link between venous thrombosis and stroke. Objective: To determine whether a preoperatively diagnosed PFO is associated with increased risk of perioperative ischemic stroke. Design, Setting, and Participants: Retrospective cohort study from Massachusetts General Hospital and 2 affiliated community hospitals between January 1, 2007, and December 31, 2015. Participants were 182 393 consecutive adults undergoing noncardiac surgery with general anesthesia. Exposures: Preoperatively diagnosed PFO. Main Outcomes and Measures: Perioperative ischemic stroke occurring within 30 days of surgery; stroke subtype by Oxfordshire Community Stroke Project classification and stroke severity by National Institute of Health Stroke Scale (NIHSS). Results: Among the 150 198 patient cases analyzed (median [SD] age, 55 [16] years), 1540 (1.0%) had a diagnosis of PFO before surgery. A total of 850 (0.6%) ischemic strokes occurred within 30 days of surgery (49 [3.2%] among patients with PFO and 801 [0.5%] among patients without PFO). In adjusted analyses, patients with PFO had an increased risk of ischemic stroke compared with patients without PFO (odds ratio, 2.66 [95% CI, 1.96-3.63]; P < .001). The estimated risks of stroke were 5.9 for every 1000 patients with PFO and 2.2 for every 1000 patients without PFO (adjusted absolute risk difference, 0.4% [95% CI, 0.2%-0.6%). Patients with PFO also had an increased risk of large vessel territory stroke (relative risk ratio, 3.14 [95% CI, 2.21-4.48]; P < .001) and a more severe stroke-related neurologic deficit measured by NIHSS (median, 4 [interquartile range {IQR}, 2-10] vs median, 3 [IQR, 1-6] for those without PFO; P = .02). Conclusions and Relevance: Among adult patients undergoing noncardiac surgery at 3 hospitals, having a preoperatively diagnosed PFO was significantly associated with increased risk of perioperative ischemic stroke within 30 days after surgery. Further research is needed to confirm these findings and to determine whether interventions would decrease this risk.
Authors: Thomas G Weiser; Alex B Haynes; George Molina; Stuart R Lipsitz; Micaela M Esquivel; Tarsicio Uribe-Leitz; Rui Fu; Tej Azad; Tiffany E Chao; William R Berry; Atul A Gawande Journal: Lancet Date: 2015-04-26 Impact factor: 79.321
Authors: Irene Meissner; Bijoy K Khandheria; John A Heit; George W Petty; Sheldon G Sheps; Gary L Schwartz; Jack P Whisnant; David O Wiebers; Jody L Covalt; Tanya M Petterson; Teresa J H Christianson; Yoram Agmon Journal: J Am Coll Cardiol Date: 2005-12-06 Impact factor: 24.094
Authors: I Meissner; J P Whisnant; B K Khandheria; P C Spittell; W M O'Fallon; R D Pascoe; M Enriquez-Sarano; J B Seward; J L Covalt; J D Sicks; D O Wiebers Journal: Mayo Clin Proc Date: 1999-09 Impact factor: 7.616
Authors: Jeffrey L Saver; John D Carroll; David E Thaler; Richard W Smalling; Lee A MacDonald; David S Marks; David L Tirschwell Journal: N Engl J Med Date: 2017-09-14 Impact factor: 91.245
Authors: John D Carroll; Jeffrey L Saver; David E Thaler; Richard W Smalling; Scott Berry; Lee A MacDonald; David S Marks; David L Tirschwell Journal: N Engl J Med Date: 2013-03-21 Impact factor: 91.245
Authors: Dana Raub; Katharina Platzbecker; Stephanie D Grabitz; Xinling Xu; Karuna Wongtangman; Stephanie B Pham; Kadhiresan R Murugappan; Khalid A Hanafy; Ala Nozari; Timothy T Houle; Samir M Kendale; Matthias Eikermann Journal: J Am Heart Assoc Date: 2021-02-26 Impact factor: 5.501